Inquest into the Death of Marshall, Tracy Margaret

Coroners Act, 1996 [Section 26(1)] Western Australia

RREECCOORRDD OOFF IINNVVEESSTTIIGGAATTIIOONN IINNTTOO DDEEAATTHH Ref No: /2013 I, Alastair Neil Hope, State Coroner, having investigated the suspected death of Tracy Margaret MARSHALL, with an Inquest held at Perth Coroners Court on 5-6 February 2013 find that the death has been established beyond all reasonable doubt, that the identity of the deceased person was Tracy Margaret MARSHALL and that death occurred on or about 21 February 2011 at an unknown location as a result of unascertainable causes in the following circumstances - Counsel Appearing : Emily Winborne assisting the State Coroner David Anderson (State Solicitor’s Office) appearing on behalf of the Nickol Bay Hospital and the WA Country Health Service.

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IINNTTRROODDUUCCTTIIOONN Tracy Margaret Marshall (Mrs Marshall) was an inpatient at Nickol Bay Hospital in Karratha when she left the hospital at about 6.19am on Monday 21 February 2011, after which she was never seen again.

Mrs Marshall had been admitted to the hospital at about 4pm on the day before, Sunday 20 February 2011.

She had told an Emergency Triage Nurse that she had “black thoughts” of self harm.

She was seen at about 4pm that day by Emergency Department Doctor, Coert Kruger, and she told him that she had made three suicide attempts the previous day.

Mrs Marshall was admitted as a voluntary patient. She left the hospital through a rear staff entrance without being discharged.

This inquest was held to investigate the suspected death of Mrs Marshall and in the event that the death of Mrs Marshall has been established beyond all reasonable doubt, into how the death occurred and the cause of the death.

TTHHEE SSEEAARRCCHH FFOORR MMRRSS MMAARRSSHHAALLLL At about 8.30am on 21 February 2011 Mr Marshall Inquest into the suspected death of Tracy Margaret MARSHALL page 2

called police and reported Mrs Marshall missing. A police “look-out to be kept for” broadcast was made in the Karratha area. It was noted that Mrs Marshall had not taken her wallet or other personal items with her from the hospital.

Police patrols were conducted in the area, including the Karratha townsite, the local tip, the Shell truck stop on the North West Coastal Highway, the back beach area and throughout the light industrial area.

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At 12pm the Karratha area went into blue alert for Cyclone Carlos. Searches continued, but their extent was limited after the Karratha area went on yellow alert at 3pm.

The Karratha district went on red alert at 2.51am on 22 February at which time searches stopped.

On 23 February 2011 searching continued. Police initiated a medical release asking the public for information and a media broadcast was conducted on local radio at 11am. Following the broadcast a telephone call was received from a member of the public who said that he had seen Mrs Marshall’s vehicle on Millstream Road, about 47 kilometres south of the Karratha townsite. He advised that he had seen the vehicle on Monday 21 February 2011 at about 11.30am parked on the side of the road. There was no-one in or around the vehicle at that time.

Police attended the scene and located the vehicle. The vehicle was parked facing away from Karratha on the left hand side of the road on the gravel shoulder.

The vehicle had overheated and was not capable of being driven. It appeared to have sustained some minor damage.

Inside the vehicle police located an empty blister pack of the deceased’s Valium medication (Valpam 5mg).

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This was possibly significant, particularly as Mr Marshall believed that there were two such blister packs missing from his home when he checked following the disappearance of Mrs Marshall.

The area surrounding the location of the vehicle was the Millstream-Chichester National Park. This park is dominated by the Fortescue River which had flooded in the weeks prior to the disappearance, cutting off vehicular tracks.

Eight police officers and five State Emergency Services staff were deployed to commence a land search.

Mr Marshall had hired an aircraft to assist with the search and that aircraft was landed at the site where the vehicle was located. Three aerial observers from the SES were placed onboard the aircraft and an aerial search was conducted along the Millstream Road.

The vehicle was subsequently examined and it was found that the lower left side of the radiator was dislodged, caused by an impact to the lower radiator support. The engine was severely overheated and the cooling system was found almost devoid of coolant. It appeared clear that the vehicle had broken down and could not be driven.

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Information from Telstra relating to Mrs Marshall’s mobile telephone indicated that activity on the telephone had been located at the Dixon cell tower. That cell tower is located north of Roebourne, to the east of Karratha.

Previous activity for the mobile telephone was recorded at the Nickol Karratha tower, at Karratha.

In respect of this information, it is possible that the activity detected at the Dixon tower resulted from Mrs Marshall’s mobile telephone accessing automatic downloads through internet roaming and its being at a location relatively close to the location where the vehicle was found. Unfortunately the mobile telephone information did not assist with location of Mrs Marshall or her mobile telephone.

Ongoing searches were conducted until 28 February 2011.

Some additional searches were conducted following information relating to the mobile telephone being received on 5 March 2011. Following that advice a 90 minute helicopter search was conducted by a Heliwest helicopter and pilot.

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AADDDDIITTIIOONNAALL EENNQQUUIIRRIIEESS Police conducted investigations with Medicare, Centrelink, the Department of Immigration and Citizenship and the Department of Births, Deaths and Marriages. There was no indication that Mrs Marshall was alive after 21 February 2011.

Enquiries were made with local taxi companies, the Greyhound and Integrity bus services, Australian Hotels Association and interstate police. No information was provided which would indicate that Mrs Marshall was alive after 21 February 2011.

Mrs Marshall’s disappearance received media coverage and was included on the National Missing Persons CoOrdination Centre website. Her father also participated in a radio interview broadcast on the ABC. Mrs Marshall has not contacted any family members or friends and no reliable sightings of her have been reported since her disappearance.

Mrs Marshall’s bank accounts have not been accessed since her disappearance.

Investigation of her accounts did, however, reveal that on 18 February 2011, three days prior to her disappearance, Mrs Marshall had transferred $20,000 and Inquest into the suspected death of Tracy Margaret MARSHALL page 7

$5,000 from one of her accounts to her Lite Transaction Account with the detail “for Kathryn”. Kathryn is Mrs Marshall’s sister. Whether or not this was significant in the context of the disappearance cannot now be determined.

CCOONNCCLLUUSSIIOONN IINN RREESSPPEECCTT OOFF TTHHEE SSUUSSPPEECCTTEEDD DDEEAATTHH Based on the above information in my view the death of Mrs Marshall has been established beyond reasonable doubt.

Mrs Marshall has not contacted family members or friends since 21 February 2011 and although extensive enquiries have been conducted, none of these have revealed any activity by her since that time.

I am satisfied that Mrs Marshall died on or about 21 February 2011.

As her body has not been located it is not now possible to determine where she died.

CCOONNCCLLUUSSIIOONN IINN RREELLAATTIIOONN TTOO HHOOWW TTHHEE DDEEAATTHH OOCCCCUURRRREEDD AANNDD TTHHEE CCAAUUSSEE OOFF TTHHEE DDEEAATTHH Mrs Marshall left the Nickol Bay Hospital on the early morning of 21 February 2011, leaving her wallet with bank cards and cash as well as other personal items at the hospital.

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Shortly after she left the hospital her husband and Ms Barrett gave the District Medical Officer, Dr Tavener, a detailed history of her bizarre behaviour and expressed their fear that she might self-harm or suicide. A decision was made at that time that if found she would be an involuntary patient and would be subject to psychiatric review.

It was clearly accepted then that it was likely she was suffering from a severe mental illness.

Based on all of the information available it appears that at the time she left the hospital Mrs Marshall was suffering from signs of a psychotic illness. She had been behaving in a bizarre manner, expressing religious ideation and had suffered strange visual phenomena on a background of poor sleep, agitation and restlessness. Her condition had appeared to be worsening and included thoughts of self-harm and suicide.

Although Mrs Marshall had been seen on a number of occasions at the Nickol Bay Hospital she had never been prescribed any antipsychotic medication. This is because it was considered important to ensure that psychotic phenomena were not masked in order to enable a definitive diagnosis to be made as to her condition. She was prescribed valium which clearly did not reduce the onset of her psychotic symptoms.

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While it is not now possible to make any positive diagnosis or to determine why it was that Mrs Marshall’s condition was deteriorating as described, it is obvious that she was displaying signs of psychotic illness, however these were being produced and her illness was not being effectively treated.

At the time when Mrs Marshall left the hospital and drove away from Karratha in her vehicle I am satisfied that she was continuing to show signs of a psychotic illness. In other words, I consider it likely that she was behaving in a bizarre manner.

It is now unclear why it was that Mrs Marshall appears to have driven her vehicle down to the MillstreamChichester National Park from Karratha or how it was that her vehicle appears to have been damaged.

It is also unclear as to why Mrs Marshall and her vehicle became separated and whether or not this was intentional on the part of Mrs Marshall.

If Mrs Marshall voluntarily left her vehicle at the side of the road and walked into the park, it is difficult to understand why it was she was not located and, assuming that she died shortly afterwards, why her body was not found.

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The fact that cyclone Carlos struck Karratha shortly after Mrs Marshall went missing had an unfortunate effect on the search for her in that it limited the extent of the search shortly after she went missing and may have removed traces of Mrs Marshall’s movements.

While Mrs Marshall had definitely expressed suicidal thoughts in the period shortly before she went missing, it is not now possible to determine whether she intentionally acted to take her own life or whether, affected by mental illness, she lost her way and died as a result of dehydration or exposure. Other possible explanations for her being missing present themselves, but in the absence of any evidence these would be pure speculation and no conclusions can be drawn.

In the above circumstances I make an open finding as to how the death arose.

A N HOPE STATE CORONER 14 February 2013 Inquest into the suspected death of Tracy Margaret MARSHALL page 11